A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.

A. Raises all four side-rails on the client's bed. Raising all four side-rails can create a risk for falls, as it may lead to a false sense of security and prevent the client from being able to exit the bed safely if needed. Additionally, it can increase the risk of entrapment or injury. The recommended practice is to keep two side-rails up while allowing for easy access and mobility for the client.
B. Locks the wheels on the client's bed. Locking the wheels on the client's bed is an appropriate action. This prevents the bed from rolling and helps ensure the client's safety, particularly when they are getting in and out of bed or during care activities.
C. Assists the client to the bathroom every 2 hr. Assisting the client to the bathroom every 2 hours is a reasonable intervention for a client at risk for falls, as it promotes regular toileting and prevents the need for urgent trips to the bathroom that could increase the risk of falling.
D. Clears furniture from the path leading to the bathroom. Clearing furniture from the path leading to the bathroom is a proactive safety measure. This reduces obstacles and hazards, promoting a safer environment for the client and minimizing the risk of falls during ambulation.

A. Cleanse skin eruptions with povidone-iodine. Cleaning the skin eruptions with a mild antiseptic like povidone-iodine can help reduce the risk of secondary bacterial infections and promote healing. Keeping the affected area clean is important in managing herpes simplex outbreaks.
B. Avoid over-the-counter topical ointments. Over-the-counter topical ointments are often recommended to help soothe the skin and alleviate discomfort during a herpes simplex outbreak. While some ointments may not be effective against the virus, it is not necessary to avoid all topical products.
C. Administer an antibiotic medication. Herpes simplex is caused by a virus, so antibiotics, which are effective against bacterial infections, would not be appropriate for treating this condition. Antiviral medications such as acyclovir or valacyclovir are indicated instead to help manage outbreaks.
D. Place disposable thermometers in the client's room. There is no specific need for disposable thermometers for a client with a herpes simplex outbreak. Standard infection control practices are sufficient, and there is no risk of contamination related to herpes that would require special thermometers.